THIEME
GLOBAL SPINE JOURNAL
Original Research
179
Adolescent Idiopathic Scoliosis and Pregnancy: An Unsolved Paradigm Josh E. Schroeder2,
Yair Barzilay3
1 Department of Developmental Biology and Cancer Research,
Hadassah Hebrew University Medical School, Jerusalem, Israel 2 Spine Unit, Orthopedic Complex, Hadassah Medical Center, Jerusalem, Israel 3 Spine Unit, Sharei Tzedek Medical Center, Jerusalem, Israel 4 Sex Dysfunction Center, Hadassah Medical Center, Jerusalem, Israel 5 Neurosurgical Department, Hadassah Medical Center, Jerusalem, Israel
Mijal Luria4
Eyal Itzchayek5
Leon Kaplan2
Address for correspondence Tal Falick-Michaeli, MD, Department of Developmental Biology and Cancer Research, Hadassah Hebrew University Medical School, Jerusalem, Israel (e-mail: [email protected]).
Global Spine J 2015;5:179–184.
Abstract
Keywords
► adolescent idiopathic scoliosis ► pregnancy ► back pain ► sexual function
Study Design Retrospective cohort study with a cross-sectional comparison. Objective To compare the rates of anesthesia prescription and satisfaction with surgery, prevalence and severity of low back pain, prevalence of depression, and sexual dysfunction among pregnant and nonpregnant patients with AIS undergoing correction surgery with pedicle-based systems and healthy woman with a history of pregnancy. Methods Women between the ages of 18 and 40 years who underwent correction surgery for AIS with a pedicle screw system were interviewed regarding pregnancies, child delivery, method of pain control during delivery, and any long-term outcome after delivery. In addition, sexual dysfunction (Female Sexual Distress Scale–Revised [FSDS]), depression (the Beck Depression Assessment Questionnaire), and Scoliosis Research Society 24 (SRS24) questionnaires were administered. Data was compared between patients with AIS without a history of pregnancy and healthy controls. Results Satisfaction with surgery in the AIS pregnant group using the SRS24 questionnaire scored 3.76/5 (p ¼ 0.0047 when compared with nonpregnant AIS group). Six of the 17 of the women with AIS had severe back pain during pregnancy (35%) mandating home treatment or hospitalization. Of the 17 women, 13 complained of a sustained back pain after child delivery (76%) that impacted their life. In the nonscoliosis group, no back pain attributed to pregnancy was reported. The rates of regional anesthesia prescription among pregnant patients with AIS who underwent correction surgery was 30% (5/17), whereas among healthy pregnant women, rates were 100% (6/6). The SRS24 scores in the patients with AIS were 72% (88/120), showing a low score of 3.69/5 in the pain domains (p ¼ 0.0048 when compared with nonpregnant patients with AIS). Depression rates were in the normal range and similar in all groups. FSDS scores, used to assess sexual dysfunction, were 4.02 in the pregnancy group and 5.67 in the nonpregnant group (not significant) and 4.6 in the nonscoliosis control group (not significant).
Both first authors contributed equally to the manuscript.
received October 30, 2014 accepted after revision March 27, 2015
DOI http://dx.doi.org/ 10.1055/s-0035-1552987. ISSN 2192-5682.
© 2015 Georg Thieme Verlag KG Stuttgart · New York
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Tal Falick-Michaeli1,
Adolescent Idiopathic Scoliosis and Pregnancy
Falick-Michaeli et al.
Conclusion Women who underwent scoliosis correction suffered from long-term back pain after pregnancy and had decreased satisfaction with surgery. In addition, anesthesiologists refused epidurals in a large number of these patients. A larger study is needed on the topic.
Study Rationale and Context
Methods
Adolescent idiopathic scoliosis (AIS) is the most common form of scoliosis.1 AIS is present in 2 to 4% of children between 10 and 16 years of age. With small curves of 10 degrees, the ratio of female to male is equal but increases to 10 females for every male with curves greater than 30 degrees.2 Women more commonly require surgical treatment for AIS than men,3 leading to long-term consequences on life. Previous publications addressing patients’ quality of life and sequela of back pain years after surgery to correct deformity demonstrated no significant impairment of health-related quality of life.4,5 With regard to pregnancy after the correction of a scoliotic deformity, 40% of the women suffered from increased low back pain during pregnancy.6 However, no significant obstetric complications or long-term orthopedic problems (such as enlargement of the scoliosis curve or diastasis symphysis pubis) were seen in these patients. In one study, the main consequence of deformity correction was anesthesiologists being less inclined to offer neuroaxial regional anesthesia to patients in labor who had undergone anterior spinal surgery.7 However, current data with posterior pedicle-based based systems is lacking.
Study Design
Objective or Clinical Question This study aimed to investigate the effect of deformity correction on pregnancy and delivery in women who have undergone surgery for AIS. The objectives of the study are: 1. To compare the rates of regional anesthesia prescription among pregnant patients with AIS who underwent correction surgery with posterior pedicle-based systems and healthy pregnant women 2. To compare the rates of satisfaction with surgery among pregnant and nonpregnant patients with AIS who underwent correction surgery with posterior pedicle-based systems 3. To compare prevalence and severity of low back pain among pregnant and nonpregnant patients with AIS who underwent correction surgery with pedicle-based systems and healthy woman with a history of pregnancy 4. To compare the prevalence of depression among pregnant and nonpregnant patients with AIS who underwent correction surgery with pedicle-based systems and healthy woman with a history of pregnancy 5. To compare the prevalence of sexual dysfunction among pregnant and nonpregnant patients with AIS who underwent correction surgery with pedicle-based systems and healthy woman with a history of pregnancy
Global Spine Journal
Vol. 5
No. 3/2015
Retrospective cohort study with a cross-sectional comparison. The project was approved by the institutional review board of the Hadassah Medical Center, Jerusalem, Israel.
Patient Population The study took place between 2010 and 2013. Seventy consecutive women between the ages of 18 to 40 years who underwent correction surgery for AIS with a pedicle screw system in Hadassah Hebrew University Medical Center, Israel, were considered for enrollment in this study. Among these, 25 (36%) had subsequent pregnancies. Among these 25 women, 5 were excluded due to postoperative complications, leaving 20 women (80%) enrolled in the AIS pregnancy cohort (►Fig. 1). Among the 45 nonpregnant subjects, 8 were excluded due to postoperative complications, leaving 37 women (82%) who were enrolled in the AIS nonpregnant cohort (►Fig. 1). For the cross-sectional cohort, 55 healthy women were approached in various acceptable public venues and signed up for study participation. Among these, 40 (73%) met study criteria and agreed to participate in the healthy women nonsurgical cohort (►Fig. 1). Six of these women (15%) experienced pregnancy and delivery. The study was approved by the Institutional Review Board of the Hadassah Hebrew University Medical Center.
Inclusion Criteria • Age restriction: 18 to 40 years old • Women who have undergone surgery for AIS with a history of one or more pregnancies • Women who have undergone surgery for AIS without a history of pregnancy • Healthy women with a history of one or more pregnancies
Exclusion Criteria • Postsurgical: women who underwent surgery with postoperative complications • Nonsurgical: patients with other medical comorbidities or major spine anomalies
Clinical Evaluation Data was collected from various sources including medical record notes, radiographic analysis reports, and information provided by women through interview.
Patient Characteristics and Risk Factors • Number of pregnancies • Age of the women in each pregnancy
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
180
Falick-Michaeli et al.
Fig. 1 Graphic breakdown of patient population. Healthy and AIS female patients were assessed for this study. They were either enrolled, or excluded, as depicted in the figure. AIS, adolescent idiopathic scoliosis.
• Type of delivery (vaginal/cesarean section) • Type of anesthesia (neuroaxial epidural anesthesia) • Measurements of the baseline scoliosis curve using fullspine standing preoperative anteroposterior and lateral radiographs of the spine • Education (high school versus academic) • Marriage (married versus not married) • Mean degrees of surgical correction of the deformity and follow up X-rays for progression evaluation of the deformity
seven questions in the pain domain, which establishes a mean pain score and indicates its severity. • Prevalence of depression was assessed using the Beck Depression Inventory score. The threshold used to diagnose women with depression was a score more than 9. • Prevalence of sexual dysfunction was assessed using the Female Sexual Distress Scale–Revised (FSDS) questionnaire. A score of 11 or greater suggests female sexual dysfunction.
Analysis Plan Radiographic Evaluation Curve extension and magnitude were assessed using the Lenke classification by two experienced fellowship-trained spine surgeons using a consensus building method.8 Patients were stratified according to the deformity in terms of type of curve pattern and curve magnitude determined by the Cobb method based on retrospective evaluation of full-spine standing preoperative and postoperative anteroposterior and lateral radiographs of the spine.
Clinical Outcomes • Rate of anesthetic methodology was measured by information provided through medical records (anesthesiology documentation system). • Satisfaction with surgery was measured using the Scoliosis Research Society 24 (SRS24) questionnaire for satisfaction with surgery domain. • Prevalence of back pain after delivery was reported by the study participants through yes-or-no responses. • Severity of back pain was measured with SRS24 questionnaire, with questions regarding general function or daily activities that are impaired because of back pain. There are
The Student t test was used to compare the nonpregnant AIS group with the pregnant AIS group with respect to continuous variables (e.g., SRS scores). The chi-square test was used to compare these groups with respect to dichotomous outcomes (e.g., prevalence of back pain). Descriptive statistics were used for the healthy cross-sectional cohort.
Results Among the 37 women enrolled in the nonpregnant AIS cohort, 14 were missing data or lacked complete follow-up, leaving 23 subjects (62%) for the analysis. From the 20 women enrolled in the pregnancy AIS cohort, 3 were missing data or lacked complete follow-up, leaving 17 subjects (85%) for the analysis. Thirty-nine pregnancies were documented in 17 women. The average age of women in the AIS group who delivered a child was 31 (range 21 to 40). The time from surgery to first pregnancy was 7.3 years (range 3 to 12 years). Compared with the general population for which the infertility rate is assumed to range between 3 and 7%, 3 patients in the AIS group had difficulty conceiving (17%) and needed to undergo fertility treatments (►Table 1). The rates of anesthetic techniques used among pregnant patients with AIS who underwent correction surgery with Global Spine Journal
Vol. 5
No. 3/2015
181
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Adolescent Idiopathic Scoliosis and Pregnancy
Adolescent Idiopathic Scoliosis and Pregnancy
Falick-Michaeli et al.
Table 1 Descriptive patient characteristics of AIS pregnant and nonpregnant women Patient characteristics
Pregnant AIS group (n ¼ 17)
Nonpregnant AIS group (n ¼ 23)
p Value
Age (average)
31(21–40)
23 (18–40)
NS
Number of pregnancies
39
0
–
Difficulty conceiving (%)
17
NA
–
Caesarean delivery
4
NA
–
Average Cobb angle correction in the surgery(degrees)
55 (40–70)
52 (35–70)
NS
Average fixation length
T4–L3
T3–L3
NS
Academic education (%)
53
60
NS
Marriage (%)
82
17
GLOBAL SPINE JOURNAL
Original Research
179
Adolescent Idiopathic Scoliosis and Pregnancy: An Unsolved Paradigm Josh E. Schroeder2,
Yair Barzilay3
1 Department of Developmental Biology and Cancer Research,
Hadassah Hebrew University Medical School, Jerusalem, Israel 2 Spine Unit, Orthopedic Complex, Hadassah Medical Center, Jerusalem, Israel 3 Spine Unit, Sharei Tzedek Medical Center, Jerusalem, Israel 4 Sex Dysfunction Center, Hadassah Medical Center, Jerusalem, Israel 5 Neurosurgical Department, Hadassah Medical Center, Jerusalem, Israel
Mijal Luria4
Eyal Itzchayek5
Leon Kaplan2
Address for correspondence Tal Falick-Michaeli, MD, Department of Developmental Biology and Cancer Research, Hadassah Hebrew University Medical School, Jerusalem, Israel (e-mail: [email protected]).
Global Spine J 2015;5:179–184.
Abstract
Keywords
► adolescent idiopathic scoliosis ► pregnancy ► back pain ► sexual function
Study Design Retrospective cohort study with a cross-sectional comparison. Objective To compare the rates of anesthesia prescription and satisfaction with surgery, prevalence and severity of low back pain, prevalence of depression, and sexual dysfunction among pregnant and nonpregnant patients with AIS undergoing correction surgery with pedicle-based systems and healthy woman with a history of pregnancy. Methods Women between the ages of 18 and 40 years who underwent correction surgery for AIS with a pedicle screw system were interviewed regarding pregnancies, child delivery, method of pain control during delivery, and any long-term outcome after delivery. In addition, sexual dysfunction (Female Sexual Distress Scale–Revised [FSDS]), depression (the Beck Depression Assessment Questionnaire), and Scoliosis Research Society 24 (SRS24) questionnaires were administered. Data was compared between patients with AIS without a history of pregnancy and healthy controls. Results Satisfaction with surgery in the AIS pregnant group using the SRS24 questionnaire scored 3.76/5 (p ¼ 0.0047 when compared with nonpregnant AIS group). Six of the 17 of the women with AIS had severe back pain during pregnancy (35%) mandating home treatment or hospitalization. Of the 17 women, 13 complained of a sustained back pain after child delivery (76%) that impacted their life. In the nonscoliosis group, no back pain attributed to pregnancy was reported. The rates of regional anesthesia prescription among pregnant patients with AIS who underwent correction surgery was 30% (5/17), whereas among healthy pregnant women, rates were 100% (6/6). The SRS24 scores in the patients with AIS were 72% (88/120), showing a low score of 3.69/5 in the pain domains (p ¼ 0.0048 when compared with nonpregnant patients with AIS). Depression rates were in the normal range and similar in all groups. FSDS scores, used to assess sexual dysfunction, were 4.02 in the pregnancy group and 5.67 in the nonpregnant group (not significant) and 4.6 in the nonscoliosis control group (not significant).
Both first authors contributed equally to the manuscript.
received October 30, 2014 accepted after revision March 27, 2015
DOI http://dx.doi.org/ 10.1055/s-0035-1552987. ISSN 2192-5682.
© 2015 Georg Thieme Verlag KG Stuttgart · New York
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Tal Falick-Michaeli1,
Adolescent Idiopathic Scoliosis and Pregnancy
Falick-Michaeli et al.
Conclusion Women who underwent scoliosis correction suffered from long-term back pain after pregnancy and had decreased satisfaction with surgery. In addition, anesthesiologists refused epidurals in a large number of these patients. A larger study is needed on the topic.
Study Rationale and Context
Methods
Adolescent idiopathic scoliosis (AIS) is the most common form of scoliosis.1 AIS is present in 2 to 4% of children between 10 and 16 years of age. With small curves of 10 degrees, the ratio of female to male is equal but increases to 10 females for every male with curves greater than 30 degrees.2 Women more commonly require surgical treatment for AIS than men,3 leading to long-term consequences on life. Previous publications addressing patients’ quality of life and sequela of back pain years after surgery to correct deformity demonstrated no significant impairment of health-related quality of life.4,5 With regard to pregnancy after the correction of a scoliotic deformity, 40% of the women suffered from increased low back pain during pregnancy.6 However, no significant obstetric complications or long-term orthopedic problems (such as enlargement of the scoliosis curve or diastasis symphysis pubis) were seen in these patients. In one study, the main consequence of deformity correction was anesthesiologists being less inclined to offer neuroaxial regional anesthesia to patients in labor who had undergone anterior spinal surgery.7 However, current data with posterior pedicle-based based systems is lacking.
Study Design
Objective or Clinical Question This study aimed to investigate the effect of deformity correction on pregnancy and delivery in women who have undergone surgery for AIS. The objectives of the study are: 1. To compare the rates of regional anesthesia prescription among pregnant patients with AIS who underwent correction surgery with posterior pedicle-based systems and healthy pregnant women 2. To compare the rates of satisfaction with surgery among pregnant and nonpregnant patients with AIS who underwent correction surgery with posterior pedicle-based systems 3. To compare prevalence and severity of low back pain among pregnant and nonpregnant patients with AIS who underwent correction surgery with pedicle-based systems and healthy woman with a history of pregnancy 4. To compare the prevalence of depression among pregnant and nonpregnant patients with AIS who underwent correction surgery with pedicle-based systems and healthy woman with a history of pregnancy 5. To compare the prevalence of sexual dysfunction among pregnant and nonpregnant patients with AIS who underwent correction surgery with pedicle-based systems and healthy woman with a history of pregnancy
Global Spine Journal
Vol. 5
No. 3/2015
Retrospective cohort study with a cross-sectional comparison. The project was approved by the institutional review board of the Hadassah Medical Center, Jerusalem, Israel.
Patient Population The study took place between 2010 and 2013. Seventy consecutive women between the ages of 18 to 40 years who underwent correction surgery for AIS with a pedicle screw system in Hadassah Hebrew University Medical Center, Israel, were considered for enrollment in this study. Among these, 25 (36%) had subsequent pregnancies. Among these 25 women, 5 were excluded due to postoperative complications, leaving 20 women (80%) enrolled in the AIS pregnancy cohort (►Fig. 1). Among the 45 nonpregnant subjects, 8 were excluded due to postoperative complications, leaving 37 women (82%) who were enrolled in the AIS nonpregnant cohort (►Fig. 1). For the cross-sectional cohort, 55 healthy women were approached in various acceptable public venues and signed up for study participation. Among these, 40 (73%) met study criteria and agreed to participate in the healthy women nonsurgical cohort (►Fig. 1). Six of these women (15%) experienced pregnancy and delivery. The study was approved by the Institutional Review Board of the Hadassah Hebrew University Medical Center.
Inclusion Criteria • Age restriction: 18 to 40 years old • Women who have undergone surgery for AIS with a history of one or more pregnancies • Women who have undergone surgery for AIS without a history of pregnancy • Healthy women with a history of one or more pregnancies
Exclusion Criteria • Postsurgical: women who underwent surgery with postoperative complications • Nonsurgical: patients with other medical comorbidities or major spine anomalies
Clinical Evaluation Data was collected from various sources including medical record notes, radiographic analysis reports, and information provided by women through interview.
Patient Characteristics and Risk Factors • Number of pregnancies • Age of the women in each pregnancy
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
180
Falick-Michaeli et al.
Fig. 1 Graphic breakdown of patient population. Healthy and AIS female patients were assessed for this study. They were either enrolled, or excluded, as depicted in the figure. AIS, adolescent idiopathic scoliosis.
• Type of delivery (vaginal/cesarean section) • Type of anesthesia (neuroaxial epidural anesthesia) • Measurements of the baseline scoliosis curve using fullspine standing preoperative anteroposterior and lateral radiographs of the spine • Education (high school versus academic) • Marriage (married versus not married) • Mean degrees of surgical correction of the deformity and follow up X-rays for progression evaluation of the deformity
seven questions in the pain domain, which establishes a mean pain score and indicates its severity. • Prevalence of depression was assessed using the Beck Depression Inventory score. The threshold used to diagnose women with depression was a score more than 9. • Prevalence of sexual dysfunction was assessed using the Female Sexual Distress Scale–Revised (FSDS) questionnaire. A score of 11 or greater suggests female sexual dysfunction.
Analysis Plan Radiographic Evaluation Curve extension and magnitude were assessed using the Lenke classification by two experienced fellowship-trained spine surgeons using a consensus building method.8 Patients were stratified according to the deformity in terms of type of curve pattern and curve magnitude determined by the Cobb method based on retrospective evaluation of full-spine standing preoperative and postoperative anteroposterior and lateral radiographs of the spine.
Clinical Outcomes • Rate of anesthetic methodology was measured by information provided through medical records (anesthesiology documentation system). • Satisfaction with surgery was measured using the Scoliosis Research Society 24 (SRS24) questionnaire for satisfaction with surgery domain. • Prevalence of back pain after delivery was reported by the study participants through yes-or-no responses. • Severity of back pain was measured with SRS24 questionnaire, with questions regarding general function or daily activities that are impaired because of back pain. There are
The Student t test was used to compare the nonpregnant AIS group with the pregnant AIS group with respect to continuous variables (e.g., SRS scores). The chi-square test was used to compare these groups with respect to dichotomous outcomes (e.g., prevalence of back pain). Descriptive statistics were used for the healthy cross-sectional cohort.
Results Among the 37 women enrolled in the nonpregnant AIS cohort, 14 were missing data or lacked complete follow-up, leaving 23 subjects (62%) for the analysis. From the 20 women enrolled in the pregnancy AIS cohort, 3 were missing data or lacked complete follow-up, leaving 17 subjects (85%) for the analysis. Thirty-nine pregnancies were documented in 17 women. The average age of women in the AIS group who delivered a child was 31 (range 21 to 40). The time from surgery to first pregnancy was 7.3 years (range 3 to 12 years). Compared with the general population for which the infertility rate is assumed to range between 3 and 7%, 3 patients in the AIS group had difficulty conceiving (17%) and needed to undergo fertility treatments (►Table 1). The rates of anesthetic techniques used among pregnant patients with AIS who underwent correction surgery with Global Spine Journal
Vol. 5
No. 3/2015
181
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Adolescent Idiopathic Scoliosis and Pregnancy
Adolescent Idiopathic Scoliosis and Pregnancy
Falick-Michaeli et al.
Table 1 Descriptive patient characteristics of AIS pregnant and nonpregnant women Patient characteristics
Pregnant AIS group (n ¼ 17)
Nonpregnant AIS group (n ¼ 23)
p Value
Age (average)
31(21–40)
23 (18–40)
NS
Number of pregnancies
39
0
–
Difficulty conceiving (%)
17
NA
–
Caesarean delivery
4
NA
–
Average Cobb angle correction in the surgery(degrees)
55 (40–70)
52 (35–70)
NS
Average fixation length
T4–L3
T3–L3
NS
Academic education (%)
53
60
NS
Marriage (%)
82
17
